Patient Applications


 Confirm on your application that you are uninsured and in addition do not have

  • Medicare

  • Medicaid (except Family Planning/

    Healthy Connections Checkup),

  • VA Health Benefits,

  • Private Health Insurance or Affordable Care Act


  Have an income that falls below 250% FPL based on the number of people in your household. Every member of the family who is working needs to have the income added to the household.



A) Proof of Identity :  

B) Proof of Address

c) Proof of Income



If you have no ID or proof of Address

If you do not possess a valid ID due to various circumstances, including homelessness, please have a credible person complete the form to support your claim


For each working member of your household proof of Income is required

Check below what document will apply to your particular case

If you and/or any household member is employed

A)  If you receive pay stubs:   Send 2 current consecutive pay stubs no older than 45 days, with no weeks missing

in between, for all members who are working.OR  most recent Tax document or W-2

B) If paid in cash : You may instead send a signed and dated letter from your/your household’s employer stating what

work is done, if there are any deductions from pay, the GROSS rate of pay, and the number of hours worked for the last

4 weeks on their Letter head Or you can print the following CASH BY EMPLOYER FORM and get it signed by Employer

Odd jobs/work for family, friends or neighbors

Send a signed and dated letter from those you/your household do work for stating what work is

done, the GROSS rate of pay (with any deductions listed), and the number of hours worked for

last 4 weeks Or Fill have them fill out the Exchange form

No handwritten letters are accepted.

If you are self employed

– Send your/your household’s most recent Federal 1040 tax return and the Schedule C – Business Profit or Loss worksheet

OR you may send a completed copy of  Shifa clinic’s

Self declaration of income

Call Us if you unable to access the form

If you have No Income

– If no one in your home has any income, submit a fully completed No-Income-Form-Apr-22 No-Income-Form-Apr-22 (3).

We need to know how you are paying for your housing, food, and utilities. The person providing support cannot live in the same household as the patient.
Call Us if you are not able to access the form

SNAP / SSI /Others

-If you have SNAP or SSI letter that will qualify you for our services and you can upload that letter as proof of income

Social Security Retirement/Social Security Disability – Send the Social Security New Benefit Amount letter showing
MONTHLY amount received for the CURRENT year.

Other Retirement/Pension/ Annuity – Send the current benefit statement showing the monthly amount received with any
deductions OR a copy of Form 1099. We cannot accept copies of checks or bank statements.

Child Support/Alimony – Send a copy of a current statement from the clerk of court or a copy of the entire divorce decree
stating amount received and how often.

 All documents can be securely uploaded on our website through the application link.

Once your completed application is received and checked for completeness we will be contacting you for your appointment scheduling.

All services at Shifa once your eligibility is verified is at no cost to you. If you have any questions please call us at 843-3524580 or email at  You can also print the application and scan or fax us at 843-375-9063




Summary of HIPAA Notice of Privacy Practices

Shifa Free Clinic complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Shifa Free Clinic protects confidential health care information, known as “Protected Health Information” (PHI). Below is a summary of your privacy rights under HIPAA. Shifa Free Clinic legal duties and privacy practices regarding your PHI are also included in this Summary Notice.

Summary of Your Privacy Rights

Shifa Free Clinic may use and give your health information to:

  • Treat you
  • Operate health care services

Shifa Free Clinic may use and give your health information for:

  • Law enforcement requests
  • Judicial and administrative proceedings related to legal actions
  • Healthcare fraud and abuse detection or compliance with the law
  • Use by another healthcare provider treating you
  • Government health oversight activities
  • Reports required by law related to births, deaths or diseases
  • Reports required by law related to neglect and abuse, or domestic violence
  • Notifying a party about exposure to a possible communicable disease
  • Military, national defense and security or other governmental functions
  • Workers’ compensation purposes and in compliance with related laws
  • Averting a serious threat to public health and safety

You have the right to:

  • Inspect or get a copy of your medical record
  • Change information on your medical record if you think it is incorrect
  • Get a list of persons with whom Shifa Free Clinic has shared your PHI
  • Ask Shifa Free Clinic to limit the information it shares
  • Ask for a copy of your privacy notice
  • Write a letter of complaint to Shifa Free Clinic or the federal government

If you have any questions, wish to file a complaint, or exercise any rights listed in this Summary or the complete Notice, please contact Shifa Free Clinic at